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Home My WebLink AboutApplication and WC O� �Y'qf? �� --=� _\'.�� TOWN OF YARMOUTH Ha�f a -� ` � `� 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 - �. �,�r�c Xf�.t• 'r Telephone(508)398-2231,ext. 1241 Div si n Fax(508) 760-3472 . To: Yazmouth Business Establishments T�+� �Ursc�. N�o`t-o2lN � , �(J�, G?�C�GOMC�D� From: Bruce G. Murphy, Director (7 � UE� Yannouth Health Department� 2 9 2014 Date: November 7, 2014 H��TH DEPT. Subject: Increase in License/Permit Fees Please be aware that the Yarmouth Boazd of Health, under the direcrion of the Yarmouth Boazd of Selectmen, has raised a number of license and permit fees issued through the Yazmouth Health Department, effective January 1, 2015. Attached is the Yarmouth Business License/Permit Application for 2015. You will note that the fees listed are the fees effecrive January 1, 2015. These fees will be due if you complete and submit the application after January 1, 2015. However, if you fully complete the application, and submit it to the Yarmouth Health Department with all required certifications and worker's compensation coverage information (certificate of insurance OR completed �davit) prior to December 31. 2014, you will be allowed to pay the 2014 rates for the following licenses: Current 2014 Fee Public Swimming Pools $ 80.00 � 30.00 Public WhirlpooUVapor Baths $ 80.00 Tobacco Sales $ 95.00 Motels $ 55.00 � SS.CX� Food Service 0-100 Seats $ 85.00 Fao3 Service Ower 10@ 3eats g15Q0� _ _ -._ _- Retail Food Service QS,OQQ sq, ft. $ 84.4D - Retail Food 3ervice >25,000 sq. ft. $225.00 Other fees owed but not listed above: $ 3s-oa CON'S1N�BREAKFq�iT Tota1 fees owed for your establishment: 1 0.00 NOTE: To be entitled to pay the current 2014 rates listed above, your business application, food and/or pool certifications, along with worker's compensation information must be received, or mailed (postmarked) on or pClor to DeCember 31, 2014. [Those establishments which open in the spring will be allowed to provide food andlor pool certif:cations prior to opening, however, you must note "Will provide in the spring prior to opening" on the applfcation.J BGM/maf ' � pC�GI� o � /� TOWN OF YARMOUTA BOARD OF HEAL ;t� �� APPLICATION FOR LICENSE/PERMIT -. � �t� Z 9 ZO�4 � : * Please complete form and attach a11 necessary docume ` �ee ber EPT. Failure to do so will result in the return of your application p ESTABLISHMENT NAME: '�1� �8 h�-a�2.L�n1 TAX ID: � . LOCATION ADDRESS: l�o �� i� �E s-yR��7N�MR a26E4 TEL.#: Sog-3�8 -3�b Z • MAILINGADDRESS: �'�w� AS A�� • E-MAILADDRESS: �N��u�+EB @ CaO�c.ep . NE'�. OWNERNAME: ax fl � �A�'5�� - CORPORATION NAME (IF APPLICABLE): P�N`I�v�fF Dfe�AT,e,�s /�� MANAGER'SNAME: 7�k45rtl+tnl � TEL.#: so$- 34�-3062 MAILINGADDRESS: IZb SEFW�F.� AvE ,S.YARrua.tT� mA a2�64 � POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. /� 1. �nv� �'+� cµ+�lr�rir+� - D4�rr� S"Tvdc,�,ySr,T 2. �q��ic�Ata� �-+��* _ Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form.The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. ��SN � Ci� �H � 2. l�A�t.�1Lt � ��40� 3. ��tC,1 i v a r� n 4. �A((n? (1.fl'n{� FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. 2• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. _ 2• _ . ALLERGEN CERTIFICATIONS: All food service establishxnents aze required to have at least one full-time employee who has Allergen certificaUon, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2• HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a �le at your place of business. 1. 2• 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# B&B $SS CABIN $55 I MOTEL $110 –b � INN $55 CAMP $55 =SWIMMINGPOOL$ll0ea _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $ll0ea. FOOD SERVICE: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 1CONTINENTAL $35 �I'S–14p NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — — —RESID.KITCHEN $SO RETAIL SERVICE: LICENSE REQOIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,OOOsq.ft. $150 _FROZENDESSERT $40 _TOBACCO $110 NAMECHANGE: $15 AMOUNTDUE _ � 2SS-00 **•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•** �Gu 't' I�ZO. O� C.i�'(� v�� .t��{ �� ADMINISTRATIdN ^� Under Ghapter 152, Sectioli 25C,Subsection 6,the Tawn af Yarmouth is now required to hold issuance or renewal of any license or permit ta operate a business if a person or company does not have a Certificate pf Worker's C:ompensation Insurance. THE ATT'ACHED STATE W4ItKER'S COMPENSATION INSTJRANCE AFFIDAVIT MUST BE COMPLETED AND SIGNEII, OR CERT. QF INSURANCE ATTACH�D OR _� WORKER'S GOMP. AFFIllAVIT SIGNED AND.�.TTACHED Town of Yarmouth taaces and liens must be paid prior to renewal oz issuance of your perrnits. PLEASE CHECK APPROPRIATELY IF PAID: YES--- �t0 MOTELS AND OTH�R LODGING FSTABLISHMENTS TIZANSIENT QCCUPANCY: For putposes ofthe limitations ofMofel ar Hotel use,Transient occupancy sha11 be limited to the temporary and short term occupancy,ordinarily and custamarily associated with motel and hotel use. 'i'ransient accupants must have and be able to demonstrate that they maintain a principal place af residence elsewhere.Transient occupancy shall generally r�fer to continuous occupancy of not rnore tlian thirty(30)days,and an ag�regate of not more than ninety(90)days within any six(6)month periad. Use of a guest wilt as a residence or dwelling unit shall nat be considered transient. tJecupaney that is subject to the collection of Room C}aeupancy Excise,as defined in M.G.L. a 64G or$30 CMR 64G, as amended, shall generally be considered Transient. YoaLs 1'OQL OPENING:All swimming,wading and whirlpooIs which have been closed for the season must be inspected by the Health Department prior to apening. Contact the Healkh Departrnent to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: 'I`he water must be tesled for pseudomonas,fotal coliform anc�standard plate caunt by a State certified lab, and submitted to the Health Departrnent three (3} days prior to opening, and quarterIy therea$er. POOL CL4SING: Every outdoor in graund swimming paol must be drained or covered within seven{7}days af closing. FOOD SERViCE SEASONAL FOOD SERVICE OPENINC':: All food service establishments must be inspected by the Health Department prior to opening. Ptease contact the Health Department to schedule the inspection three(3)days prior to opening. CATERING POLICY: Anyane who caters within the Town of Yarmouth tnust notify the Yarxnouth Health Department by filing the required Temporary Foad Service Application form 72 haurs prior ta the catered event. These forms can be obtained aY the Health Department,or from tha Tawn's website at www.varrnouth.ma.us under Health Department, Downloadable Farms. FROZEN DESSERTS: Frozen desserts must be tested by a Staze certified lab prior to apening and monthly thereafter,with sample results submitted to the Health Deparhnent. Failwre to do sa will result in the suspension or revocation of your Frozen I)essett Permit until the above terms have bcen met. OUTSII}E CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health. OUTDOOR COQHING: Outdoor aooking,prepazation,or display of any food pzoduct by a retail or fpod service establishment is prohibited. NOTICE:Pezmits run annually from January T to December 31. IT IS YOUR I2ESPONSIBILI'I'Y TO RETLJRN THE COMPLBTED RENTWAL APPLiCATZON{S)AiVD REQIJIRED FEE(S}BY D�CEMBER 15, 2014. ALL RENOVATIONS TO ANY FOQD CSTABLISHMENT, MO'T'EL OR POOL (i.e., PAINTING, NBW EQUIPMENT,ETC.},NNST BE REPORTED TQ AIvTI}APPROVEL}BY THE BOARD OF HEALTH PRIQR TO CQMMENCEMENT. RENOVATIONS MAY REQiJIRE A SITE PLAN. DAT�: SIGNATURE: PR1NT NAME &TITLE: � Rev. i1f03114 . • � The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite I00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: �u r�ES l�o�o FL �� Address: a�o S�+�=.� � • �o2�`�H �7N mA o2G6¢ � �o$ - �7�f- �6� Z : City/State/Zip: `�a'�-� i Phone#: Are ygu an employer?Check the appropriate box: Business Type(required): 1.�� I am a employer with ,3 employees(full and/ 5. ❑ Retail or part-rime).* 6. ❑ RestauranUBaz/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, � Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] $• ❑Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* l l.�ealth Caze 4.❑ We aze a non-profit organization,staffed by volunteers, �� with no employees. [No workers' comp. insurance req.] 12. Other •Any applicant thaz checks box#1 must also fill out the section below showing the'v workers'compensatioa policy iafolmatioa. **If the coxpornte officers have exempted themselves,but the corporation has other employees,a workecs'compensation policy is required mmd such an organization should check box#1. � . I am an employer that is providing workers'compensa[ion insurance for my emp[oyees. Below is the policy informntion. Insurance Company Name: �'.,I A`'++2� �"�S�`2�iG� �e»,P 9*�r ES' Insurer'sAddress: D��ti ��NF�LL � ��3 �tiRNaDu4k I�-�' � �• O. �� 14R6 CiTy/State/Zip: �'�`�h�NiS � M� 07�0 � Policy#or Self-ins.Lic.# ws��U g � 2� 2� �� Expiration Date: b7 I� ��'V S . Attach a copy of the workers' compensation policy declaration page(showing the policy number and eapiration date). Failure to_secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries of a - _-�-�— ___ _ — --- -- -- _ - — - fine up to $1,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Invesrigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and pena[ties of perjury that the information provided above is true and correct Sienature: ��a^'�- Date: � ZI I � � ` Phone#: Ojficial use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's O�ce 6. Other Contact Person: Phone#: www.mus.gov/dia Rightfax C1-1 7/l0/2014 5:56:04 AM PAOE 2/003 Fax Sezver A��' CERTIFICATE OF LIABILITY INSURANCE �';�„ TFNS CER7�ICATE 18 ISSUED AS A MATTER OF INFORMIITION ONI.Y Ml� CONFERS NO RIONTB UPON THE CERT�iGTE - 1pLDER. 71#S CERTiFlCi1TE DDES llOi AFFRtM11TVElV LAt NEGAT1VaY AMERD�DREf1D Wt ALTER TNE COVEAAGE � AFFORDED BY 7HE POLICIEb BELOW. THIS CERTIFlCATE OF INSIIRANCE DOES NpT CON87RUTE A CONTRA6T BEIYYEEN . 71E ISSUING INfURER(S�.AUTNOI�D REPRFSENTA7NE OR PRDd10ER,AND TME CERTIRCIITE HOLDER MPORTAIR: N IM nniRcats hokl��is an ADDrt10NAL INSYRED,Na policy�iss)muet bs endor[�d. If SUBROGATION IS WANE0. �. aub�et b the tei�rid con�tions of tlro PWkY,urlyn PWkies mar n9uire an sadonanen� A atatement on this eatYWU dm aW conM rlgMs to IM dltll�b Iroltler M Ilw M wiCh�menqs). � RGOYCER CON14C1 � IiNME: DOWLING 6 ONEIL WS oHope nx - 9731YANNOUGH ROAQ HYANNIS,MA 02fi0t E-�� - WBN/E�461�samo�cwvEMtE x�nc• '. . MAUFERl1:�AM��NBUR+WCECpMMrv . � INBWIEN B� - PENNY WISE OPERATIONS LLC 4 BALLEFUIIA COURT ��"�' � NASHUA,NH a1082 msur�n o: - MSURERE: M6tH1ERF� . ES CEH7IFICATE NUA�ER• REVISION NUYBEA: � TH19 IS TO CERTIFV TNAT THE POLIqE9 OF IMSUR/WCE I�STEO OELOW MAVE BEEN 133UE0 TO THE INSUREO NAMED ABOVE FOR THE POLICV PERIOD INDICATED. 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